Single centre experience of transperitoneal radical tumour nephrectomy

Objective: To share the experience of radical nephrectomy through transperitoneal approach

Material and methods: After approval from ethical committee and the consent from patients a retrospective study vas conducted extending from January 2012 to January 2014 to identify clinical characteristics of renal ell carcinomas, staging, per operative and early post operative complications. The study included all renal cancer patients presented to Sheikh Zayed Hospital Lahore with in this specified period. Detailed history nd physical examination was performed. Haematological and radiological investigations including ibdominopelvic ultrasonography and CT scan abdomen and pelvis were performed to stage the renal umour. High resolution CT chest was performed where indicated. Radical nephrectomy performed hrough transabdominal approach and outcomes measured in terms of per-operative and early postoperative complications

Results: There were total of 50 cases. The male to female ratio was 3:2. Vlean age of patients was 52.38 [18-93] years. Most common clinical presentation was gross haematuria [66%]. The mean tumour size was 8.34 [3-24] cm. Operative findings were suggestive of tumor limited to Gerota's fascia in 40 patients [80%] and in 6 [12%] tumor was extending into renal vein or inferior vena cava. In these cases, venacavatomy had to be performed. Lymphadenectomy was performed in 2 patients [4%] who were having enlarged hilar lymph nodes. Total operative time ranged between 120 to 180 minutes. Intra-operative splenic injury was seen in 2 [4%], while aortic injury was observed in one [2%] patient. Post operatively one [2%] developed pulmonary embolism, 2 [4%] chest infection while 2 [4%] developed wound infection and 3 patients [6%] required blood transfusion. Tumour histology was clear cell in [84%], papillary transitional cell carcinoma [12%] and oncosytoma contributed 4%

Conclusion: We observed that large number of the patients presented with haematuria and most of them were male. Radical nephrectomy along-with removal of tumour thrombus is a valuable method for the treatment of renal cell carcinoma having tumour thrombus either in renal vein or inferior vena cava. Common pathological type was clear cell carcinoma

Culprit artery characteristics and severity of angiographic thrombus burden in primary percutaneous coronary intervention in patients presenting with ST elevation myocardial infarction

The purpose of study was to characterize culprit artery characteristics in terms of presence of thrombus burden in patients with acute myocardial infarction using prevalent parameters of thrombus estimation. Descriptive study. Adult cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] October 2011 to 31[st] September 2012. We studied 119 patients treated with primary percutaneous coronary intervention for ST- segment myocardial infarction. Bare metal stents were used in all patients as per hospital protocol. Thrombus burden [TB] was graded [G] as GO = no thrombus, G1= possible thrombus, G2 = small [greatest dimension <, 1/2 vessel diameter [VD]], G3 = moderate [>1/2 but <2 VD], G4 large [>2 VD], G5 = unable to assess TB due to vessel occlusion. Patients with G5 were reassessed after passage of guide wire or small balloon for thrombus burden. Frequency of major adverse cardiac events [MACE]-defined as death, myocardial infarction and infarct- related artery revascularization was recorded for the pen-procedural period which was defined in our study up to 72 hours. Overall, in hospital MACE was 8.4%. Large thrombus burden is a significant predictor for mortality and MACE

Efficacy and safety of transradial approach in primary PCI for STEMI

To determine the efficacy and safety of transradial approach in primary percutanous intervention in acute ST segment elevation myocardial infarction. Descriptive study Emergency reporting [ER] department of Armed Forces Institute of Cardiology National Institute of Heart Diseases [AFIC/NIHD] from Dec 2011 to Dec 2013 Retrospective data of 354 patients had been collected through records. All the patients presented with acute myocardial infarction to emergency reporting [ER] department of Armed Forces Institute of Cardiology National Institute of Heart Diseases were included in the study. All the patients underwent primary coronary intervention through transradial route. All patients received IIB IIIA inhibitors bolus and infusion. The primary end points were procedure success and local access site hematoma and secondary end points were major bleeding requiring blood transfusion and door to balloon time. The mean age of the patient was 64 +/- 18 years, there were 251 [70.9%] males and female were 103 [29.1%]. Radial access site cannulation time was 194 +/- 22 sec and door to balloon time was 78 +/- 14 min. Procedural success was 349 [98.6%]. Forearm hematoma was noted in 4 [1.12%]. No major bleeding requiring transfusion was noted. Primary percutanous intervention [PPCI] via transradial [TRI] route in acute STEMI patients can be achieved with high success and low complications in our population. The clinical outcome is matching with local and international data

Frequency and angiographic characteristics of coronary artery ectasia in patients undergoing coronary angiograms at AFIC and NIHD

To determine the frequency and angiographic characteristics of coronary artery ectasia in the patient population of AFIC and NIHD. Descriptive Study Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi from Jan 2007 to Dec 2011. All coronary angiograms done during the period were included in the study. The reports of coronary angiograms of those patients who were diagnosed to have coronary artery ectasia were left circumflex artery reviewed to assess the distribution of ectasia in different coronary arteries. Concomitant significant coronary artery stenosis left ventricular [LV] systolic function and history of revascularization were also documented. Over the study period, a total of 41,459 patients underwent coronary angiograms. 548 [1.32%] patients were diagnosed to have coronary artery ectasia. Out of these 467 [85.21%] patients were males and 81 [14.78%] were females. Their mean age was 53.7 years. Left anterior descending [LAD] was the coronary artery, most commonly affected by ectasia followed by left circumflex artery [LCx] and Right coronary artery [RCA]. Twenty three patients also had ectasia of left main stem. Four Hundred and three [73.54%] patients also had concomitant occlusive coronary artery disease and 19.52% patients had history of coronary revascularization either by percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]. Coronary artery ectasia is not a benign disorder as it could present as acute coronary syndrome having its own morbidity and mortality

Frequency of common modifiable risk factors in patients with myocardial damage undergoing single vessel coronary angioplasty

To determine the frequency of common modifiable risk factors in patients with myocardial damage undergoing single vessel coronary angioplasty. Descriptive study. Armed forces Institute of Cardiology / National institute of Heart Disease Rawalpindi from June 2012 to Nov 2013. Hundred patients undergoing elective single vessel percutaneous coronary angioplasty were evaluated with creatinine kinase and creatinine kinase MB levels before, after 8 hours and 24 hours following coronary angioplasty. The detailed performa was filled from each patient covering the necessary variables. Out of 100 patients 22% had raised creatinine kinase at 8 hours and 43% had raised creatinirie kinase after 24 hours following coronary angioplasty. Whereas 19% patients and 38% patients had raised creatinine kinase MB levels at 8 hours and 24 hours following the procedure respectively. No patient had rise of creatinine kinase or creatinine kinase MB more than 3 times of normal limits in the study. Among patients with raised CK-MB highest frequency was of diabetes mellitus, raised LDL levels, smoking and hypertension. Patients with raised CK-MB levels after 1[st] day of coronary angiography had diabetes mellitus [84%], raised LDL levels [79%], smoking [68%] and hypertension [58%]

Procedural outcome of primary PCI inst-segment elevation myocardial infarction at Afic and Nihd Rawalpindi - Pakistan

To determine the procedural outcome of primary percutaneous coronary interventions [PCI] in ST segment elevation myocardial infarction. A quasi-experimental study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, a tertiary care cardiac institute from November 2011 to September 2013. Total 228 patients who underwent primary percutaneous intervention [primary PCI] were included in this study. A pre designed performa was prospectively filled which included demographic and procedural variables. Procedural success and in hospital mortality were recorded. The mean age was 59 +/- 10.88 years. There were 205 [89.9%] males, 80 [35.1%] patients were found to be diabetic, 47 [20.6%] hypertensive, and 90 [39.5%] patients were smokers. Family history of ischemic heart disease was positive in 51 [22.4] patients. Anterior, inferior and lateral myocardial infarction were present in 137 [60.1%], 90 [39.5%] and 1 [0.4%] patients respectively. The Median time from the onset of symptoms to the arrival in the hospital was 122.5 +/- 142.57 and median door to balloon time was 60 +/- 22.88 min. Left anterior descending [LAD] was the commonest infarct related artery accounting for culprit artery in 138 [60.5%] followed by right coronary artery [RCA] and left circumflex artery [LCX] in 72 [31.6%] and 18 [7.9%] cases respectively. Procedural success was achieved in 222 [97.4%] patients. Six [2.6%] patients died in the hospital. High success rate with low mortality rates can be achieved in our set up. However more studies and long term follow up is required to validate our results

Role of aspiration thrombectomy in primary PCI for STEMI - myth or reality?

The objective of the study was to determine the outcome of thrombus aspiration in Primary coronary intervention [PCI] for ST elevation myocardial infarction [STEMI]. Case Series The study was carried out in Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] over a period of twelve months from January 2013 to December 2013. Data of 30 patients who underwent aspiration thrombectomy during primary PCI for STEMI by the transradial approach was collected. Inclusion criteria were chest pain suggestive of myocardial ischemia lasting longer than 30 min accompanied by ST- segment elevation or new left bundle branch block on the ECG within 12 h of symptom onset. Patients with previous CABG, cardiogenic shock or requiring TPM placement were excluded from this study. A 6F sheath was placed inside the radial artery, and cardiac catheterization was performed. Angiographic and electrocardiographic signs of myocardial reperfusion were assessed. Study endpoints included TIMI III flow and ST-segment resolution at the end of the procedure. Mean age of the patients was 52 years [range 37-77 yrs] and 63% [n= 19] were males and 37% [n=11] were females. The right radial artery was used in 90% of cases. Thrombus aspiration catheter used was 6 F Thrombuster II [70%] and Hunter [30%].There was significant improvement in markers of myocardial reperfusion with achievement of ST-segment resolution and TIMI 3 flow in 28 patients [93%]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia, compartment syndrome or MACE was observed. Thrombus aspiration [TA] is applicable in the majority of patients undergoing primary PCI for myocardial infarction with ST-segment elevation, and it improves early markers of myocardial reperfusion

Successful implantation of percutaneous left ventricular assist device [impella 2.5] in AFIC/NIHD - first time in Pakistan

Impella 2.5 is a miniaturized percutaneously inserted left ventricular assist device [LVAD] that can be placed via a retrograde approach across the aortic valve using a femoral arterial access. It helps in reducing the cardiac workload and provides circulatory assistance and protection to the myocardium and vital organs in patients with severe left ventricular systolic dysfunction. It has been used in patients with heart failure, cardiogenic shock [CS], and high-risk patients undergoing percutaneous intervention [PCI].We report here our experience using an Impella 2.5 catheter in a patient with high-risk percutaneous intervention [PCI]

Intestinal tuberculosis presenting as acute abdomen

To study the outcome of intestinal tuberculosis presenting as acute abdomen. Descriptive Study. Bolan Medical Complex Hospital [BMC] Quetta and Combined Military Hospital [CMH] Quetta from Nov 2003 to Nov 2005 from Bolan Medical Complex and from Nov 2005 to Nov 2006 in CMH Quetta. Thirty seven patients of acute abdomen presenting with intestinal obstruction were admitted; 28 from emergency department and 9 from out patient department. Twenty seven patients were from BMC and 10 from CMH Quetta. Patients were diagnosed as having abdominal tuberculosis on the basis of operative findings and histopathological reports. Out of 37 patients presenting with acute abdomen due to intestinal obstruction, 54% were male and 46% were female with M: F ratio of 1: 1.2. Age of the patient ranged from 20 to 50 years, with maximum frequency between 30 to 40 years. Abdominal pain was the commonest presenting feature in all patients followed by constipation in 81.1% patients. Peritonism was seen in 27% patients. Different operative procedures performed were adhesionolysis 65.8%, segmental resection 7.9%, right hemicolectomy 10.5%, stricturoplasty 7.9% and ileostomy 1.3%. Mesenteric lymph node biopsy 40.8%.Intestinal tuberculosis is still a very important surgical problem in our country presenting as acute abdomen. A suspicion must always be kept during laparotomy and adequate tissue histopathology should supplement the diagnosis.

Initial experience with the novel mguard stent system for percutaneous coronary intervention at AFIC-NIHD

To assess the efficacy of the MGuard Stent in Percutaneous coronary Intervention [PCI] in the setting of acute coronary syndromes. Interventional case series. Distal embolisation during PCI occurs in acute coronary syndrome from the thrombus occluding the artery. The consequences can vary from a simple sluggish flow to myocardial infarction and death. A number of protective devices reduce distal embolisation, but they add complexity and cost to the procedure. The balloon expandable MGuard stent is a unique innovation to counter the phenomenon. We sought to study its efficacy in the proposed indications. The study was conducted in AFIC - NIHD. Between April and July 2010, 18 patients were included and a total of 21 MGuard stents were deployed. Inclusion criteria were de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolisation in the setting of acute coronary syndromes. Use of filter wires or other proximal or distal protective devices was not allowed in the study. Primary end point included the incidence of MACE [composite if cardiac death, non-fatal MI and need for TLR] up to 30 days after the procedure. Secondary endpoints included restoration of TIMI grade 3 flow and myocardial blush grade 3 at the end of the procedure. All patients were male. Mean age was 45.61 years [range 32-70 years]. All were admitted with acute coronary syndrome. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI- grade III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedures in any patient, and no MACE was reported at 30 days [primary end point]. These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis

Otitis media: comparison of outcome of underlay versus overlay myringoplasty

To compare the outcome of underlay versus overlay myringoplasty procedure in the management of otitis media. This comparative study was conducted at the Department of Ear, Nose, Throat, Head and Neck Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from January 2008 to December 2009. It included eighty-six patients with dry ears for at least six weeks and no focus of infection in nose, sinuses or throat were included in the study. Forty three patients underwent underlay technique while other 43 patients were operated through onlay techniques. Myringoplasty was performed in total of 86 patients. Male were 69 [80.02%] and females were 17 [19%]. Thirty-five [40.70%] of them belonged to age group of 10-25 years. Thirty [34.88%] were in the age range of 26-35 years, while 21 [24.42%] aged between 36-45 years with mean age of 27.48 +/- S.D 10.20 years. Overall success rate of graft uptake was noted in 70 [81.40%] out of 86 cases. All 86 cases were equally divided into two group's i.e. 43 patients in each group. Thirty-eight out of 43 perforated drums were treated with underlay techniques having success rate of 88.37% as compared to 32 out of 43 patients with only techniques where the graft uptake was 74.4%. Underlay technique is more successful statistically as compared to overlay technique of myringoplasty in all age groups

Nasal involvement in cutaneous leishmaniasis

To determine the frequency of nasal involvement in cutaneous Ieishmaniasis and to study demographic and clinical pattern of disease involving nose as well as nasal mucosa. Patients with cutaneous leishmaniasis presented to leishmaniasis clinic situated in the Basic Health Unit for Afghan refugees at Sarai Gambeela, District Lakki Marwat from January 1, 2009 to December 31, 2009 were registered. The patients were diagnosed clinically and confirmed by laboratory demonstration of parasite in a giemsa stained smear prepared from the lesion. Those having lesions primarily on nose, irrespective of age and gender were included in the study. All those cases with primary lesion elsewhere over face and secondarily involving nose [creeping lesion] were excluded. All important clinical details were recorded on a specially designed proforma and patients were given a registration card for the purpose of treatment and follow up visits. Sixty seven out of' 682 [9.82%] cases of nasal leishmanisis were encountered. Male to female ratio was 2:1. Forty nine [73.13%] had solitary lesions and among these fourty four [65.67%] had lesions limited to their nose. Wet type cutaneous leishmnaniasis was seen in 19 [28.36] cases. Seventy three percent of sufferers were less than 30 years of age. Cutaneous leishmaniasis is endemic in Distt. Lakki Marwat. Nose was a common site of involvement. In endemic areas, it should be included in the differential diagnosis of nasal lesions

Headache, the patient burden, demographics and disability as experienced in neurology OPD clinic at Shaikh Zayed Hospital, Lahore

This study has found high prevalence of the headache presentation in neurology clinic attendants, at Shaikh Zayed Hospital, Lahore, with I 6.55 of patients presenting with complains of headaches. The prevalence is higher in female patients as compared with male patients. The most affected age group was between 21 to 30 yrs of age. Disability assessed using MIDAS [Migraine Disability Assessment Score] questionnaire was found to be as high as 48.7%. Headache is thus a common problem in the neurology outpatient clinic causing significant distress and disability: It is therefore important to provide the best available treatment and support to headache patients in order to minimize the impact of headaches disorder

Idiopathic hyper-eosinophilic syndrome [IHES] presenting with peripheral neuropathy: a case report

A 40 years old man presented with excruitiating pain and numbness in all 4 extremities and pain cpigastrium. After thorough investigations he was diagnosed as a case of idiopathic hypereosinophilic syndrome [IHES] and successfully treated with oral prednisolone, following which the patient is doing well. This case is being reported as IHES presenting with peripheral neuropathy is rarely seen

Assessing the potential of intravenous thrombolytic therapy in acute ischemic stroke in our setting

Background and purposes: Intravenous thrombolytic treatment with alteplase has shown to improve clinical outcomes significantly in patients with acute ischemic stroke when administered within 4.5 hours of onset of first symptom. Our study aims to determine how many stroke patients reached the Accident and Emergency of a tertiary care health facility in Lahore, Pakistan within the 4.5 hour time limit. Moreover we also set out to see how many stroke patients got imaging done [CT scan/ MRJ] with in the 4.5 hours from the onset of first symptoms at the tertiary care facility. Through this study we may be able to assess if intravenous thrombolysis has any potential of being offered to ischemic stroke patients in our setting

Methods: 100 consecutive stroke patients presenting to our Accident and Emergency [A and E] Department over a period of 29 days [20[th] September 2008 to 19[th] October 2008] were included in this study. It is a questionnaire based cross sectional study in which convenience sampling was carried out. The questionnaire assessed the time span between onset of 1[st] symptom to the presentation at our A and E Department. Along with this, the questionnaire also aimed to assess the time span between onset of first symptom to the time imaging [CT scan/MRI] was done. In our study we also inquired if the patient was taken initially to a primary care facility before being referred to our facility and whether the time span between onset of first symptom and primary care physician contact was less than 4.5 hours. Type of stroke incurred was also recorded although no exclusion criteria was set out on the basis of type of stroke

Results: Among the 100 patients questioned 9 patients reached the A and E [Accident and Emergency] Department within 4.5 hours of onset of first symptom. Of these 9 patients; 4 patients had their imaging [CT scan/MRJ] done within the 4.5 hour time limit from the appearance of the first symptom. 21 patients reached a primary care physician within the specified time limit but none of them reached the tertiary care facility within the time limit

Conclusion: When comparing our results to similar studies conducted in other countries, a larger proportion of our stroke patients did not reach the Accident and Emergency Departments within the specified time period. As a result, comparatively speaking intravenous thrombolysis has a lesser potential of being offered to ischemic stroke patients in our setting